For Clerk’s Use Only Name of Person Filing: ___ Mailing Address: ___ City, State, Zip Code: ___ Daytime/Evening Phone Number: ___ ATLAS Number (if applicable) ____________________________________ Attorney Bar Number (if applicable) ____________________________________ Represented by Self or by Attorney SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY Case Number: APPLICATION FOR CHANGE OF NAME FOR AN ADULT In the Matter of: _________________________________ Applicant STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION 1. INFORMATION ABOUT ME, THE APPLICANT A. Name on Birth Certificate (Applicant) or Current Legal Name _________________________ _________________________ _________________________ (First) (Middle) (Last) County of Residence:__________________________________ Date of Birth:_________________________ Place of Birth:_______________________________________ (Month / Day / Year) (City / State / Nation) 2. I ask that my name be changed to: _________________________ _________________________ (First) 3. _________________________ (Middle) (Last) I ask that the birth records be changed to reflect the new name listed above. 4. REASON FOR THIS REQUEST FOR CHANGE OF NAME I request that the name be changed as listed above for the following reason(s): _____________________________________________________________________________________ _____________________________________________________________________________________ 5. ADDITIONAL STATEMENTS A. Has the applicant listed above been convicted of a felony? Yes B. Are felony charges pending in any jurisdiction? No Yes No If yes list the charge(s)________________________________________________________________ 9/22/2006 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case No.___________________________ C. The applicant acknowledges that he/she is not knowingly changing their name to that of another individual for the purpose of committing theft, forgery, credit card fraud, business and commercial fraud, perjury or any offense involving false statements. D. This application is made solely for the best interest of the person named above. It will not release the persons from any obligations incurred or harm any rights of property or action in any original name. OATH OR AFFIRMATION STATE OF ARIZONA ) ) ss. COUNTY OF MOHAVE ) The contents of this document are true and correct to the best of my knowledge and belief. Signature:______________________________________ Date:____________________________ Sworn to or affirmed before me on this __________________ day of _________________, 20_____________ By: ______________________________________ My Commission Expires:_____________________ 9/22/2006 ______________________________________ Notary Public or Deputy Clerk Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com